The election of President Trump in 2016 was accompanied by a promise of major healthcare reform. The Trump Administration has committed to repealing and replacing the Affordable Care Act (ACA) with a less expensive healthcare bill, which will cover more Americans and provide more comprehensive coverage. While the Republicans’ goal is to repeal much of the ACA, there are aspects that Republicans seem to plan on keeping in place.

One such aspect is the provision banning insurance underwriting based on pre-existing conditions. Prior to the ACA, insurers could deny coverage to those with a pre-existing medical condition, which left millions of Americans without health insurance. This provision was one of several that expanded coverage to many Americans who could not previously obtain health insurance due to pre-existing health conditions.

However, Republicans dislike and want to repeal the counterpart to this provision: the individual mandate. Under the individual mandate, Americans are required to obtain health insurance coverage or pay a tax penalty. The purpose of this provision was to balance the risk pool insurers faced. Without this provision, it is thought that unhealthy and older individuals would seek health insurance, but young and healthy individuals would abstain from obtaining coverage. If the risk pool contained only unhealthy, older individuals, insurers would be forced to provide costly coverage with little to no chance of achieving profitability and would be unlikely to continue to provide coverage to individuals through the ACA Insurance Exchanges.

Republicans view the individual mandate, and the potential tax penalty that accompanies it, as a huge burden on the American people. However, if the individual mandate is repealed, it is unlikely that the provision prohibiting insurer discrimination based on pre-existing conditions will remain successful. The repeal of the individual mandate is likely to result in a decrease in the enrollment of healthy, young individuals in health insurance, leaving an extremely risky pool of insureds seeking coverage. With such a risky pool, there is no guarantee that insurers will opt into participation in the ACA Insurance Exchanges for 2018, and many Americans may again be left without health insurance coverage.

The precarious balance between the pre-existing condition provision and the individual mandate provision demonstrates the complexity of the issues the Trump Administration and Republicans are facing. Aside from these two provisions there remain numerous complicated substantive and procedural issues​ that must be addressed before the Affordable Care Act is repealed and replaced, and so far, the Trump Administration has not elaborated on how it plans to address such issues.

Lacey Rogers is a 3L at DePaul University College of Law graduating in May of 2017 with her J.D. and Health Law Certificate.